Diagnostic Fads

When a prominent psychiatrist in the American Psychiatric Association (APA) blogs about ‘Psychiatric Diagnosis Gone Wild: The “Epidemic” Of Childhood Bipolar Disorder’, it catches your attention.

This is especially notable since Allen Frances, MD was past chair of the DSM-IV Task Force and of the Department of Psychiatry at Duke University School of Medicine, Durham, NC. Currently he is Professor Emeritus at Duke Universtity.

Tip

Beware of diagnostic fads

A press release from the National Institute of Mental Health (NMIH) in September 2007 stated that “the number of visits to a doctor’s office that resulted in a diagnosis of bipolar disorder in children and adolescents increased by 40 times over the last decade. Over the same time period, the number of visits by adults resulting in a bipolar disorder diagnosis almost doubled.” The cause of these increases is unclear. Medication prescription patterns for the two groups were similar. The study was published in the September 2007 issue of the Archives of General Psychiatry.

Disturbed and disturbing kids are very often encountered in clinical, school, and correctional settings. They suffer and cause suffering to those around them—making themselves noticeable to families, doctors, and teachers. Everyone feels enormous pressure to do something. Previous diagnoses (especially conduct or oppositional disorder) provided little hope and no call to action. In contrast, a diagnosis of childhood Bipolar Disorder creates a justification for medication and for expanded school services. The medications have broad and nonspecific effects that are often helpful in reducing anger, even if the diagnosis is inaccurate.

B. Here’s what he said (in italics) was the “engaging story”:

The “epidemic” of childhood Bipolar Disorder fed off the engaging storyline that it:
1. Is extremely common
2. Was previously greatly under-diagnosed
3, Presents differently in children because of developmental factors
4. Can explain the variety of childhood emotional dysregulation
5. Has diverse presenting symptoms (eg, irritability, anger, agitation, aggression, distractibility, hyperactivity, and conduct problems)

C. Here’s what he said (in italics) was the “influential prophets”:

The prophets were “thought leading” researchers who encouraged child psychiatrists to ignore the standard bipolar criteria and instead to make the diagnosis in a free-form, over-inclusive way. Then enter the pharmaceutical industry— not very good at discovering new drugs, but extremely adept at finding new markets for existing ones. The expanded reach of childhood Bipolar Disorder created an inviting target. The bandwagon was further advanced by advocacy groups, the media, the internet, and numerous books aimed at suffering parents.

This is not a diatribe about Bipolar Disorder, however it is quite easy to put a diagnostic label on people. It is much harder to erase that label from the patient/client, from the patient/client’s identity and from other peoples’ view of that person. Dr. Frances alerts us about the dangers of over-diagnosing childhood Bipolar Disorder. But as you consider the following points that I quote him in italics, there is much food for thought about any diagnosis we place upon a person.

The massive over-diagnosis of childhood bipolar disorder comes with large costs. Inappropriately-diagnosed children are often treated with medications that are unnecessary and potentially quite harmful (especially those that cause rapid and substantial weight gain, increasing the risk of diabetes, and possibly reducing life span).

Other more specific causes of irritability may be missed. For example, Attention Deficit Disorder often presents with an irritability that responds best to stimulants, but these may be withheld in the face of an incorrect bipolar diagnosis. Substance abuse should always be the first thought for irritable teenagers.

The label Bipolar Disorder also carries considerable stigma, implying that the child will have a lifelong illness requiring lifetime treatment. Many causes of temper outbursts are much shorter lived and amenable to time-limited treatment.
The diagnosis can distort a person’s life narrative, cutting off hopes of otherwise achievable ambitions. People worry about getting married, having children, or taking on stressful ambitions, jobs, or work challenges.

It may become more difficult to get insurance. An incorrect diagnosis of bipolar disorder may reduce one’s sense of personal responsibility for, and control over, undesirable behavior. People sometimes use the diagnosis as an excuse for interpersonal or legal problems.

The “epidemic” of childhood Bipolar Disorder has created a public health dilemma. Based on much hype and very little scientific evidence, a huge and heterogeneous cohort of explosive kids has received powerful treatments that can sometimes do much good, but sometimes do much harm. How do we tame the fad? Merely rewriting DSM5 cannot cure what has become the deeply ingrained habit of over-diagnosing and over-treating childhood Bipolar Disorder

If you are in a position to actually designate and document diagnoses, in many ways this is a sacred trust we should not take lightly, especially psychiatric diagnoses.

If you are not officially qualified to decide the diagnosis or are the recipient of a diagnosis, there are still important attitude and treatment implications to consider here.

1. People are not their diagnostic label

Recently, I was interviewing a client who is on long-standing disability for a variety of diagnoses including Schizoaffective Disorder, Borderline Personality Disorder, and Polysubstance Dependence (methamphetamine, cocaine and marijuana). Much of the conversation revolved around these ‘topics’: his diagnoses; his understanding of the dynamics about his self-defeating patterns of substance use; the negative effects of substance use on his psychiatric symptoms; how he was spending so much time recycling cans to raise funds for his daily heavy marijuana use; how despite his intent to stop his methamphetamine and crack use, he nevertheless felt that marijuana helped his psychiatric stability.

I was a bit slow to shift the focus away from his litany of pathology and eventually caught myself. “What brings you joy?” I finally asked. Quickly he answered “running”. He prided himself on being fairly physically fit and in the past has done some distance running. He even talked about wanting to become a fitness trainer. Now we were onto conversation which did not define him by his psychiatric diagnoses.

This led to our highlighting a few issues which would directly pertain to becoming a fitness trainer:

Couldn’t he make much more money as a trainer, than recycling aluminum cans?
Why not restart his daily running routine instead of spending so much time hustling recycling cans?

Would daily marijuana use help or hinder his fitness and competence as a trainer?
What would it take to become a trainer? What would be some first steps? Would remaining homeless living on the streets help or hinder his becoming a trainer?

Increasingly I avoid thinking of clients as alcoholics, schizophrenics, borderlines, obsessive compulsives, sociopaths, narcissists, drug addicts, bipolar or manic depressives. Rather they are a father, mother, brother, sister, daughter, son, cousin or grandparent who happens to have alcohol dependence, schizophrenic disorder, borderline personality issues, or who suffers from obsessive-compulsive disorder or bipolar disorder.

I know we often encourage people new to AA to self-identify as “Hi, I’m Joe and I’m an alcoholic”. But if that identity remains their identity and their sense of self to the exclusion of growing beyond the grips of alcohol dependence over their life, then we have failed them. We have contributed to their becoming their diagnostic label instead of embracing wellness, health and recovery.

Whenever I visit the exhibit hall of an addiction conference, I ask the program representatives the daily rate of their residential program or the daily rate of their intensive outpatient program. Many times the answer that comes back is something like: “The thirty day program is $20,000; and the extended care program is $35,000.” I then clarify my question and ask again about the daily rate since not everyone may need the 28 or 30 days. The answer: “I’m not sure what the daily rate would be, as we want everyone to stay for the whole program.”

Recently, I asked the same question in an exhibit hall; happily, I was quoted a daily rate more than the program rate. In the 1980’s I was the Director of a hospital-based addiction program. It was a 21 day inpatient program. Therefore if your diagnosis was Substance Abuse or Dependence, you were admitted to the 21 day program.

Here are some tips to consider about diagnosis-driven, program-based treatment as opposed to person-centered services:

“How long do I have to be here?” – Instead of quoting a set number of program weeks or sessions, say something like: “Well it depends on what you are wanting to work on here – total abstinence? cutting back or whether you even think you have an addiction problem or not? Then we have to do an assessment and see what we would recommend. Then you and I have to collaborate and agree on a service plan.

Then we have to work hard together on that plan and see if it works. So I don’t really know how long that will take. It depends on things like: Are you working hard and showing up literally and figuratively? Or are you just sitting in sessions and not involved? It depends on whether the plan we agree on is the best and whether it is working.”

Diagnosis is a necessary but insufficient determinant of treatment – You want to know if a person has an addiction problem so that you know if they even need addiction services. Or whether they have a mental health or physical health diagnosis so you know if they need mental and/or physical health services. Or whether they have an addiction and mental health problem so you know if they need co-occurring disorders treatment.

But the diagnosis alone does not determine the treatment and certainly does not define the level of care and the length of stay. (Think about how you treat the diagnoses of Schizophrenic Disorder, Bipolar Disorder, Major Depression, Asthma, Diabetes and Hypertension.There are no 28 day schizophrenic disorder programs or 3 week hypertension intensive outpatient programs.)

Focus on improved function and outcome, not graduation and program completion – What counts in treatment is not whether the client can list off the criteria of their diagnosis, but whether they are being attracted into taking responsibility for their thoughts, behavior and choices in life. A thorough understanding of a person’s diagnosis is of little value if their life is not improving and if they are not experiencing improved function, joy and peace. As Dr. Frances said “The diagnosis can distort a person’s life narrative, cutting off hopes of otherwise achievable ambitions.”

So does all this mean that it is bad to give and use diagnoses?
If I am not well and life is not good, I certainly would want to understand if there is a diagnosis which explains my dysphoria and what can be done about it.

However..
If the diagnosis now controls and disempowers me; if it reduces me to comply with others’ regulations and program limits; if it limits my potential to embrace as much joy and serenity as possible, then the diagnosis is a disservice. The problem is not making a diagnosis. It is in misusing it to stifle creativity and person-centered and person-directed care; to push compliance with treatment instead of collaboration for positive outcomes and joyful recovery.